Editing Operations for crohn's disease

== '''Pre-op''' ==

* Anti-TNF agents (infliximab, adalimumab, certolizumab) - a/w increased operative complications - controversial
** Ideally last dose >4/52 pre-op
** UC - possible a/w pelvic sepsis after IPAA - 3-stage approach favoured in patients on anti-TNF drugs
** CD - possible increase in complications, but controversial and not clear
** Vedolizumab 
*** Ideally last dose 4-8/52 pre-op
*** UC - no increased risk of infection
*** CD - similar rates of infection to anti-TNF drugs
** Ustekinumab
*** Similar complication rates to anti-TNFs
*** Ideally last dose 4/52 pre-op
** Restart 4/52 post-op where necessary
* Corticosteroids
** Well-established detrimental effect on anastomotic healing
** UC: should do delayed IPAA formation in patients who cannot be weaned to <20mg/day for 6/52 pre-op
** CD - high risk of infection is generally ameliorated by stoma instead of primary anastomosis
*** Should still be reduced if possible
* Nutrition
** UC - no pre-op TPN
** CD - poorly studied in biologic era, but no clear role for pre-op TPN
*** Still need to optimise nutrition
* Planning
** Pre-op imaging is crucial +/- capsule endoscopy
** Looking for important disease in other areas of GIT
** Planning extent of resection

== '''Elective surgery''' ==

* Principles:
** Attempt laparoscopy (safe in localised abscesses, simple intra-abdominal fistulas, perianastomotic recurrent disease, and disease limited to TI)
** Control symptoms
** Maintain function
** Preserve bowel length
** Margins: 2cm where bowel is grossly normal (palpate along '''mesenteric''' border to determine involvement)
** Fistulae involving healthy, innocent, bystander segments of bowel should be treated with wedge resection rather than requiring two separate bowel excisions
* Faecal diversion if:
** Adequate nutrition and minimal intra-abdominal sepsis - no diversion
** Malnourished (albumin <20) and septic patients - diversion
** Sabiston says peri-op biologic use is not a contra-indication to primary anastomosis
* Anastomosis: controversial but '''no clear preference for technique or configuration'''
** End to end or side to side ok
** Stapled or hand-sewn ok
** Kono-S style has shown promise, under investigation currently
** It seems to be safe, and may decrease risk of recurrence, but there is a low overall level of evidence (level IV as of June 2020)
**
* Internal bypass procedures - avoid wherever possible due to risk of malignancy
* Mesentery - treat with great care - prefer clamp with Kocher clamps then suture ligate rather than ligasure
**
* Small bowel disease - document length in every CD operation unless unsafe to do so. <200cm is high-risk for short bowel syndrome, while <100cm almost certainly require parenteral nutrition.

== '''Stricturoplasty''' ==

* See 'Crohn Disease' section for indications and contraindications
* Procedure: 
** Start by examining the entire small bowel, and developing a 'roadmap'
** Then can plan to deal with individual obstacles as they arise
**
* Short segment (<10cm):
**
** Longitudinal antimesenteric incision from 2cm proximal to 2cm distal, then close transverse in one or two layers
* Fistulous tract:
**
* Size mismatch:
**
* Intermediate-segment (10-20cm): Finney-type or Jabouley
*** Form U-shape
*** Longitudinal incision halfway between mesenteric and antimesenteric sides throughout the loop
*** Opposed edges are sutured together to form an isoperistaltic enteroenterostomy in two layers - basically a long side-to-side anastomosis
**** Interrupted seromuscular sutures to align back wall - outer posterior layer
**** Continuous full-thickness inner layer along back wall
**** Transition onto front wall around corner - either Connell or switch back to continuous over-and-over
**** Tie front wall in middle
**** Often unable to do a second layer front wall due to poor compliance of bowel
*** Shouldn't be done with strictures longer than 15cm (concerns for bacterial overgrowth)
**
* Long (>20cm): side-to-side isoperistaltic strictureplasty. Remember to biopsy site for malignancy.

* Colonic strictures are associated with very high recurrence (>50%) so segmental colectomy is not often the best option

== '''Post-op''' ==

* A well-functioning stoma allows a much better quality of life than a poorly-functioning anorectum 
** Leakage
** Skin irritation
** Difficulty maintaining a seal
** Retraction
** Ischaemia
** Mucocutaneous separation
** Pyoderma gangrenosum can develop around stoma sites (2-5% of those who have stomas for IBD)
*** Early recognition and corticosteroid treatment
*** Good stoma care
* Ileostomy creation high-risk for readmission
** AKI + dehydration common
* Infection - high-risk overall, particularly with immunosupression
** Intra-abdominal sepsis reportedly 8%, median nine days post-op
** High-risk: previous intestinal resection + triple therapy immunosuppressed (22% overall risk)
** Anastomotic leaks: particularly those with multiple previous resections
*** Stapled side-to-side anastomosis have lower leak rates
* Stump blow-out
** Oversewing staple line and decompressing rectal tube are purported to decrease blowout rate, but limited evidence
** Can also bring above fascia to secure either below skin or as mucus fistula
* Pouch complications:
* VTE - more common than would be expected - consider 4 weeks prophylactic clexane
* ERAS is vital
* CD predictably recurs at or proximal to previous anastomosis, especially in smokers, patients with perforating disease, or patients who have had a prior resection
** No risk factors = 3 months metronidazole
** One or more risk factors = 3 months metronidazole + thioprine/TNF inhibitor
** Colonoscopy should be done 6 months post-op
**

[[Category:Small bowel]]